Below average — CMS composite of the measures below.
The next survey window likely opens around May 2027
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Briarcrest Nursing Center during CMS and state inspections, most recent first.
Improper Food Storage and Disposal: The facility failed to discard opened refrigerated soup within the required time frame and failed to keep frozen hashbrowns fully covered and sealed. During kitchen observation, the DS found chicken noodle soup still in the refrigerator beyond the allowed period and an opened bag of hashbrown potatoes in the freezer that was not fully closed; the DON noted the potatoes appeared freezer burned. Facility policy required refrigerated soups to be discarded within 2-3 days and frozen foods to be covered, labeled, dated, and kept sealed.
Failure to document and monitor continuous oxygen therapy: A resident with pneumonia, schizophrenia, and dementia was observed on continuous O2 via nasal cannula, but the MAR did not document oxygen administration, O2 sat was not monitored every shift, no care plan addressed the resident's continuous oxygen use, and no No Smoking/Oxygen in Use sign was posted at the room entrance while an oxygen concentrator was present.
Medication Refrigerator Stored at Improper Temperature: A medication room refrigerator used for newly received refrigerated meds was found at 28 degrees Fahrenheit, below the facility’s 36 to 46 degree range. Three emergency kits labeled Keep Refrigerated and one vial of Procrit were stored inside, including insulin pens and lorazepam vials. The LVN stated the meds were at risk of freezing, and the DOM said the refrigerator had been set to a freezing level rather than the proper refrigeration setting.
Failure to Inform a Resident of Restriction from the Nurses’ Station: A resident with intact cognition, moderate ADL assistance needs, and hearing loss was not told why he could not go to the nurses’ station. He stated he felt ignored and denied information about decisions affecting him. Facility leadership and staff stated residents should be treated with dignity, kept informed, and given clear explanations, and the Resident Rights policy required kindness, respect, dignity, communication, and access to people and services.
Failure to obtain and update informed consent for psychotropic medications: one resident with schizophrenia, bipolar disorder, epilepsy, and MDD had Depakote ordered without documented informed consent before initiation, and another resident with DM, CKD, and severe cognitive impairment had duloxetine consent that was not updated when the indication changed from depression to pain management for diabetic neuropathy. RN, ADON, and DON interviews confirmed the consent process and indication documentation were incomplete.
A resident with dementia, psychosis, and heart failure repeatedly refused Midodrine and an ordered ammonia level while receiving Divalproex Sodium. The MAR and progress notes did not show timely physician notification of the repeated refusals, and the consultant pharmacist’s recommendation for an ammonia level was also not documented as being communicated to the MD. Staff interviews confirmed the refusals occurred over multiple consecutive days, and the DON stated the physician should have been informed.
A facility failed to develop comprehensive care plans for three residents with ongoing treatment needs. One resident receiving oxygen for COPD and related lung conditions had no care plan for oxygen therapy, another resident prescribed diabetic medications including dapagliflozin-pro-metformin, pioglitazone, and glargine insulin had no care plan addressing the regimen or monitoring needs, and a third resident ordered midodrine for hypotension had no care plan for the medication. The DON and LPNs confirmed the missing care plan interventions during record review.
A resident with COPD, pleural effusion, chronic pulmonary edema, and asthma was observed receiving 4 L of oxygen by nasal cannula, but the chart contained no active physician order for oxygen therapy. The LVN and DON both stated oxygen is a medication and should not be given without an order, and the facility’s oxygen policy requires verification of a physician order before administration.
Failure to Maintain Fingernail Hygiene: Two staff-dependent residents had fingernails that were long, untrimmed, and/or dirty, despite needing assistance with ADLs and grooming. One resident with dementia and maximal ADL dependence had long fingernails with debris under the nail bed, and staff stated nail care was part of CNA duties and should be checked daily. Another resident with dementia, polyarthritis, and tinea unguium had thick, yellow, overgrown fingernails, and staff and leadership acknowledged the nails needed trimming and that the facility’s nail care policy called for daily cleaning and regular trimming.
A resident with dementia, DM, and muscle weakness was observed with a broken bed headboard hanging away from the bed frame, and staff confirmed it was not securely attached. Another resident with moderate cognitive impairment and DM was observed with a lighter and cigarette on the bedside table, while the smoking assessment had not been updated after he was found smoking in his room and smoking materials were not properly secured.
Failure to monitor and document Foley catheter care for a resident with an indwelling urinary catheter. The resident had neuromuscular bladder dysfunction, a hx of UTI, and impaired decision-making. The care plan directed staff to document urine color, sediment, cloudiness, odor, blood, and output each shift, but the TAR did not show consistent monitoring. The TN and ADON stated the missing documentation increased the resident’s risk for infection and CAUTI.
Failure to provide required feeding assistance: A resident with dysphagia, dementia, and severe cognitive impairment was ordered a pureed, mildly thick diet with a feeder. Surveyors observed the resident twice eating without staff assistance, cueing, or supervision, including scooping food with fingers while a meal tray was positioned over the lap. CNA and DON both confirmed the resident required direct meal assistance and should not have been left to eat independently.
Pharmacist MRRs for two residents receiving Depakote/Divalproex recommended ammonia level labs, but the DON found no documentation that the physician was notified or that the recommendations were addressed. One resident had schizophrenia, bipolar disorder, epilepsy, and major depressive disorder and was on Depakote for seizures; the other had dementia, psychosis, and heart failure and was on Divalproex for mood swings and yelling. The DON stated ammonia levels were necessary for both residents, and the facility’s MRR policy required the consultant pharmacist to provide a written, signed, dated report of irregularities and recommendations.
A resident with DM received scheduled insulin even when blood glucose readings were below the ordered hold parameter, and another resident with dementia, psychosis, and heart failure received Midodrine even when SBP was above the ordered hold parameter. The DON, RN, and LPN interviews confirmed the medications were administered outside the prescriber’s parameters, and the records showed the doses were given despite values that required the medications to be held.
Fortified Diet Not Served as Ordered: A resident with HTN, dysphagia, and dementia was ordered a fortified, minced and moist diet with moderately thick consistency, but during a meal observation the resident’s lunch tray did not include the fortified mushroom soup listed for fortified diets. The DS, RN, and DA all stated the diet order should have been communicated and followed so the correct tray could be prepared and served.
Failure to Follow EBP During Repositioning: A CNA repositioned a resident on EBP without wearing the required PPE. The resident had dementia, severe cognitive impairment, and was dependent on staff for ADLs, with an active order for EBP due to a urinary catheter and unhealed wounds. The CNA stated she forgot to don a gown before care, and the DON confirmed that repositioning required gloves and a gown before resident contact.
Inaccessible Call Light for Resident with Bilateral Mittens: A resident with hemiplegia and dementia was observed in bed with mittens on both hands while the call light was placed across the chest, making it impossible to activate independently. The resident’s care plan called for use of the call light for assistance, and RT confirmed the resident needed an alternative adaptive call system because the resident could not grasp the device while wearing the mittens.
Failure to Document Fall Precautions Each Shift: A resident with CVA, hemiplegia, aphasia, dysphagia, and severe cognitive impairment was identified as a fall risk and had care plan interventions for a low bed, wedges, and bilateral floor mats. Nursing notes did not document shift-to-shift checks of these fall precautions, and the resident was later found on the floor mat with eye bleeding and a laceration; CT showed a right medial orbital wall fracture.
Two CNAs violated privacy and confidentiality requirements when one CNA used a personal cell phone to record and photograph two residents during a perceived altercation and then sent the video to another CNA. The residents, who had significant medical conditions including paraplegia, seizures, dysphagia, and severe cognitive impairment, were dependent on staff for ADLs. The second CNA reported that a family member later took her phone without permission, accessed the contents, and transmitted the videos and photos to facility leadership. Facility staff, including an LVN, the DSD, and the administrator, stated that HIPAA rules and facility policies prohibit staff from recording residents on personal devices and allow resident photographs only with consent and for medical purposes as part of the chart, and that the facility’s "Stop and Watch" process requires observation and reporting, not filming.
A resident with severe cognitive impairment and multiple psychiatric and orthopedic diagnoses alleged that a CNA hit her during a shower. An RN reported performing a full body assessment and identifying a bluish discoloration on the resident’s hip, but this assessment was not documented in the medical record and was instead placed only in an abuse investigation file. The Change of Condition documentation noted notification of the PCP about the abuse allegation but did not reflect a head-to-toe assessment, did not record the discoloration, and did not show that the PCP was informed of the bruise. The RN was unable to reach the PCP and did not escalate to the Medical Director, contrary to facility P&P requiring injury assessment, documentation, and physician notification after incidents and abuse allegations.
A resident with respiratory failure, hypoxia, and dependence in multiple ADLs was transferred to a GACH for G-tube replacement, but the facility did not provide the required written Bed-Hold notice to the resident’s responsible party at the time of transfer. The Business Office Manager indicated nursing was responsible for issuing Bed-Hold notices, while the DON reported that staff only verbally informed responsible parties and was unaware of the written notice requirement. Review of the facility’s Bed-Holds and Returns P&P showed that residents or representatives must receive written bed-hold information twice, including at the time of transfer, but this second written notice was not provided.
A resident with dementia, depression, anxiety, and a recent femur fracture alleged being hit during a shower, prompting an RN to perform a head-to-toe assessment and identify a bruise on the hip. The RN documented this finding only on a separate paper form used for an abuse investigation, not in the medical record or on the Change of Condition (COC) form. The COC instead recorded that the PCP was notified and included a PCP recommendation to monitor for pain and sadness, even though the RN later stated the PCP had not been reached and that this recommendation was incorrect. The COC also omitted any reference to the full body assessment or the bruise, contrary to facility policy requiring complete, accurate, and objective documentation of assessment findings and physician notification.
A resident with bipolar disorder, COPD, and HTN was prescribed quetiapine for aggressive angry outbursts, with the care plan and orders requiring every-shift monitoring and documentation of target behaviors. For an extended period after the antipsychotic was initiated, nursing staff did not perform or document the required behavior monitoring, despite facility policies mandating observation and reporting of specific behaviors and medication efficacy. RN and DON interviews confirmed that this monitoring was necessary for the physician to evaluate treatment effectiveness and consider dose adjustments or GDR, but it was not carried out as ordered.
Two roommates became involved in a verbal altercation over cigarettes and a cell phone that one resident had entrusted to the other while away at a GACH. Nursing staff de-escalated the initial argument and left both residents in the same room, despite a facility policy requiring separation of residents after an altercation. The residents remained together overnight, and the conflict resumed the next morning, when one resident pushed the other into a nightstand, causing a documented eyebrow abrasion. Multiple staff, including an RN, LVNs, the SSD, the DON, and the Administrator, later acknowledged that the residents were not separated after the first altercation as required by policy, and that a room change should have been implemented.
A resident with bipolar disorder, COPD, and HTN, receiving quetiapine for aggressive outbursts and identified on PASRR Level 1 as having a serious mental illness, was admitted under a physician-certified 30-day exempted hospital discharge. Although the resident’s stay extended beyond 30 days, the facility did not submit the required PASRR Resident Review Level 1, despite a Level 2 letter and state guidance specifying that a new Level 1 must be completed if the stay exceeds 30 days. The MDS nurse and DON acknowledged that the resident remained in the facility past 30 days and that the facility was responsible for resubmitting the Level 1 screening in accordance with facility policy and DHCS PASRR requirements.
A resident with dementia, generalized muscle weakness, and chronic atrial fibrillation, who was severely cognitively impaired and dependent on staff for several ADLs, was observed in bed with bilateral grab bars used for mobility and repositioning. Review of records showed no MD orders for grab bars and no person-centered care plan addressing the use of side rails or related safety interventions over an extended period. An RN and the DON both acknowledged that a care plan should have been in place to describe the reason for the grab bars and to direct staff monitoring of the resident’s use, positioning, and the condition of the equipment, in accordance with the facility’s comprehensive care plan policy.
Surveyors found that staff installed bilateral bed grab bars for two residents with impaired cognition and significant physical limitations without completing accurate side rail utilization assessments, obtaining physician orders, or documenting informed consent. In both cases, the medical record assessments indicated no side rails in use or requested, yet grab bars were observed on the beds and used for mobility and repositioning. Review of active orders and the eHR showed no orders or consent documentation, despite facility policy and the DON’s statements that an order, assessment, and informed consent were required before bed rail use.
A resident with intact cognition and decision-making capacity, who had multiple chronic conditions, requested that staff stop informing a previously designated family emergency contact about his care to avoid causing her worry. This request was documented by an RN, yet another nurse later notified the same family member of a change in the resident’s condition involving respiratory symptoms. The resident reported feeling frustrated and distrustful, and both the RN and DON acknowledged that the resident’s right to privacy and autonomy was not honored and that the emergency contact information was not updated to reflect his wishes, contrary to facility policies on resident rights and confidentiality.
A resident with severe cognitive impairment, total dependence for ADLs, high Braden risk, and a Stage 4 trochanteric PI was ordered to use a P.R.O. Plus LALM for wound management. Facility education and staff statements indicated that only a thin sheet and a disposable pad should be used on the LALM to maintain its pressure redistribution function. However, surveyors observed multiple layers between the resident and the mattress, including extra sheets and a pad used to facilitate repositioning and prevent sliding. Staff acknowledged this was contrary to the LALM guidelines, and the DON and treatment nurse confirmed that excess linen layers interfered with the mattress’s intended pressure-relieving effect, resulting in a deficiency for failure to follow LALM linen-use protocols.
A resident with hemiplegia, hemiparesis, aphasia, severe cognitive impairment, and documented fall risk was care planned and ordered to have bilateral half side rails and two-person assistance for bed mobility and repositioning. Despite this, a CNA provided incontinence care and repositioned the resident onto her side alone, without checking the Kardex and without side rails in place, contrary to the care plan and facility policy. During this one-person repositioning, the resident shifted, slid, and rolled off the bed to the floor, demonstrating the facility’s failure to implement ordered safety devices and required staffing support during repositioning.
A resident with severe cognitive impairment and total dependence on staff alleged to his responsible party that he was hit by an unidentified male CNA. The DON and Administrator were made aware of the allegation but did not report it to the State Agency within the required timeframe, despite facility policy and federal requirements mandating prompt reporting of abuse allegations.
A resident with severe cognitive impairment and total dependence on staff for care alleged being hit by an unidentified male CNA, as reported by the responsible party. Despite facility policy and federal requirements mandating investigation of all abuse allegations, both the DON and Administrator acknowledged that no investigation was conducted into the reported incident.
A resident with severe cognitive impairment and multiple complex medical needs did not receive neurological assessments at the required frequency after an alleged head injury by a CNA. The RN responsible failed to perform neuro-checks at the scheduled intervals, with some checks delayed and others clustered together, contrary to facility policy and physician orders. The DON confirmed the assessments were not completed as required.
The facility did not adequately protect resident-identifiable information or maintain medical records according to professional standards, resulting in a deficiency related to privacy and documentation requirements.
A resident with dementia, epilepsy, and anxiety disorder, who required maximal assistance with ADLs and had fluctuating mental capacity, did not have an individualized care plan developed to address dementia. Nursing staff confirmed the absence of a care plan, despite facility policy requiring comprehensive, person-centered plans with measurable objectives.
A resident with a history of heart failure and kidney disease was admitted with physician orders for fluid restriction and use of a condom catheter for I&O monitoring. Despite documented changes in the resident's condition, including worsening edema and respiratory distress, staff interviews and record reviews confirmed that no comprehensive, resident-centered care plan was developed or updated to address these needs, in violation of facility policy.
A resident with a documented seafood allergy and multiple dietary restrictions was served pureed fish after staff failed to properly identify the allergy on the tray card and did not adequately verify the meal before service. The resident consumed the fish, experienced an allergic reaction, and required medication. Staff interviews revealed that the allergy was not clearly marked on the tray card and that required double-checks of meal trays were not performed.
Staff failed to wear required PPE and ensure proper signage while providing wound care to two residents on Enhanced Barrier Precautions (EBP). An LVN and a restorative nursing assistant performed dressing changes without isolation gowns, despite physician orders and facility policy mandating PPE use for residents with open wounds and MDRO risk. Both residents had significant cognitive and physical impairments and required extensive assistance with daily living.
A resident with multiple chronic conditions was left with a cup of medications at her bedside by an LVN, without supervision or an IDT assessment for self-administration. The resident had not been evaluated for her ability to self-administer medications, and there was no physician order permitting this practice. Facility staff confirmed that medications should not be left unattended and that an IDT assessment is required before allowing self-administration, as outlined in facility policy.
A resident with a history of chronic respiratory failure and tracheostomy dependence experienced sustained tachycardia and tachypnea, but nursing staff did not promptly assess or notify the physician as required by facility policy. Despite documentation of abnormal vital signs for several hours, the physician was not contacted until later in the day, resulting in delayed treatment and transfer to an acute care hospital.
Two residents experienced deficiencies in accident prevention and supervision. One resident, dependent on staff for bed mobility and toileting, was repositioned by a CNA without required two-person assistance, resulting in a fall and bilateral femur fractures requiring surgery and transfusion. Another resident, at high risk for falls, did not have a call light within reach or fall mats in place as specified in the care plan, increasing the risk of injury. Facility policies and care plans requiring these safety measures were not followed.
The facility did not ensure that an MDS nurse demonstrated required competencies or received annual evaluations of her ability to accurately perform MDS assessments. Despite access to the RAI manual and periodic audits of completed assessments, there was no direct observation or formal evaluation of the nurse's performance, as required by facility policy. This failure placed all residents at risk of inaccurate MDS assessments and care planning.
The facility did not implement required infection control measures for several residents, including failing to post EBP signage for two residents with indwelling devices, not changing respiratory equipment as per policy for two residents, and leaving suction equipment on the floor for another resident. These actions were confirmed through observations, record reviews, and staff interviews, and were not in accordance with facility policies.
A resident with severe cognitive impairment was admitted with a personal blanket, which was laundered by staff but not labeled or returned. The blanket was later found in storage, and the lack of labeling led to staff being unaware of its ownership, resulting in the resident not maintaining possession of her belonging.
Two residents with significant physical and cognitive impairments were unable to access their call lights due to improper placement, and one resident did not receive needed assistance to wear her prescribed bifocal glasses. Staff interviews confirmed awareness of the residents' limitations and the importance of individualized call light placement and support with adaptive devices, but these needs were not consistently met.
Four residents did not receive accurate MDS assessments, with errors including failure to document vision needs, extremity impairments, dental status, and accurate levels of dependence for ADLs. MDS nurses did not follow RAI manual protocols or facility policy, leading to assessments that did not reflect residents' actual conditions as documented in medical records, therapy notes, and CNA documentation.
A resident with multiple mental health diagnoses was identified as needing a Level II PASRR evaluation to determine eligibility for specialized mental health services, but the evaluation was not completed or followed up on. Facility staff, including the SSD and MDS nurse, were unfamiliar with the PASRR process and responsibilities, and there was no policy or procedure in place to ensure required PASRR evaluations were conducted.
Several residents did not have care plans developed or implemented for critical needs, including fall prevention, insulin administration, seizure and anticoagulant medications, use of corrective lenses, dental status, and safety devices. Staff interviews and record reviews confirmed that these omissions left staff without guidance on required interventions and monitoring, resulting in unmet resident needs.
Two residents with severe cognitive impairment and ADL deficits were found with long, dirty fingernails and toenails, despite care plans and facility policy requiring daily cleaning and trimming. Staff confirmed that nail care was their responsibility and acknowledged the deficiency in providing necessary hygiene assistance.
A resident with severe cognitive impairment, morbid obesity, and high risk for pressure ulcers was found lying on a low air loss mattress that was set above their actual weight, contrary to facility policy and manufacturer guidelines. Nursing staff confirmed the incorrect setting, which resulted in the resident being on a harder surface not suitable for their skin integrity needs.
Improper Food Storage and Disposal
Penalty
Summary
The facility failed to ensure opened and refrigerated soup was discarded within the required time frame and failed to ensure frozen hashbrowns were covered and sealed. During a concurrent observation and interview on 6/1/2026 at 8:50 a.m. in the kitchen, a container labeled chicken noodle soup dated 5/25/2026 was observed in the refrigerator. The Dietary Supervisor stated the soup should not have remained in the refrigerator and should have been discarded three days after being opened. During the same observation, an opened bag of hashbrown potatoes was seen in the freezer and was not fully closed. The Dietary Supervisor stated the bag should have been sealed, and the DON stated the potatoes appeared freezer burned. During interview on 6/4/2026, the DON stated kitchen staff should ensure foods were stored according to facility policy and that failure to properly store and dispose of food placed residents at risk for foodborne illnesses. Facility policy stated all foods stored in the refrigerator or freezer are to be covered, labeled, and dated, frozen foods are to remain solid, wrappers of frozen foods must stay intact until thawing, and refrigerated soups should be disposed of within 2-3 days.
Failure to document and monitor continuous oxygen therapy
Penalty
Summary
Adequate respiratory monitoring, documentation, and oxygen signage were not completed for one resident who had pneumonia, schizophrenia, and dementia and was severely impaired in daily decision making and dependent on staff for toileting, bathing, and dressing. After the resident developed a productive cough, the physician ordered oxygen at 4 liters per minute via nasal cannula as needed for O2 saturation less than 95 percent, and the resident was observed receiving 3 liters of continuous oxygen via nasal cannula at the bedside. The resident's MAR did not document oxygen administration, and LVN 5 stated the nurse who administered oxygen should have documented it in the MAR. RN 1 stated licensed nurses were expected to document every medication and treatment administered to residents, and that failure to document oxygen administration placed the resident at risk for inconsistent nursing care and inadequate respiratory monitoring and assessments. The facility's Oxygen Administration policy stated documentation of oxygen administration is to include the signature and title of the person recording the data. The resident's records also did not show oxygen saturation monitoring every shift, and no order was present to check O2 saturation every shift. LVN 5 stated the resident's oxygen saturation should have been checked every shift to ensure the O2 sat parameter of 95% was being met and monitored, and RN 1 stated residents receiving continuous oxygen should have orders to check O2 sat every shift. In addition, no care plan was developed to address the resident's continuous oxygen use, and no No Smoking/Oxygen in Use sign was posted at the room entrance while an oxygen concentrator was present at the bedside.
Medication Refrigerator Stored at Improper Temperature
Penalty
Summary
The facility failed to maintain the medication refrigerator within the required temperature range for medications intended for resident use in one medication refrigerator reviewed. During a concurrent observation and interview, the refrigerator in the medication room was found to display 28 degrees Fahrenheit, while the temperature log on the door listed the acceptable storage range as 36 to 46 degrees Fahrenheit. Three emergency medication kits labeled Keep Refrigerated were stored inside the refrigerator along with one vial of medication. Each emergency kit contained one Novolin Regular insulin injection pen, one Humalog Lispro insulin injection pen, and two 1 mL vials of lorazepam. One vial of Procrit was also observed in the refrigerator with pharmacy labeling stating that it must be refrigerated and not frozen. The LVN stated the temperature was below freezing and that the medications were at risk of freezing. The DOM stated the refrigerator had been set to a freezing level rather than the appropriate refrigeration setting, and the DON stated refrigerated medications must be maintained within the pharmacy's recommended range of 36 to 46 degrees Fahrenheit.
Failure to Inform Resident of Restriction from Nurses’ Station
Penalty
Summary
The facility failed to ensure that Resident 73 was informed of the reason for being restricted from the nursing station. Resident 73 was originally admitted and later readmitted to the facility, and diagnoses included type 2 diabetes, a left acetabulum fracture, and bilateral hearing loss. The Minimum Data Set dated 5/6/2026 indicated the resident’s cognitive skills for daily decision making were intact, the resident required moderate assistance with activities of daily living, and the resident had moderate difficulty hearing. During an interview on 6/4/2026 at 8:12 a.m., Resident 73 stated he did not matter at the facility because he was not told why he could not go to the nurses’ station. The resident stated he felt ignored and was denied information about decisions affecting him. Interviews with the ADON, RN 3, RN 1, and the DSD indicated residents should be treated with dignity, kept informed, and given clear explanations, and that failure to do so may cause residents to feel ignored, devalued, excluded, and as though they do not belong or matter. The facility’s Resident Rights policy stated employees must treat residents with kindness, respect, and dignity and provide communication and access to people and services inside and outside the facility.
Failure to Obtain and Update Informed Consent for Psychotropic Medications
Penalty
Summary
The facility failed to implement its Psychotropic Medication Use/Informed Consent policy for two residents by not ensuring informed consent was properly obtained and documented for psychotropic medication use. Resident 14 had diagnoses including schizophrenia, bipolar disorder, epilepsy, and major depressive disorder, and was assessed as cognitively intact with capacity to understand and make decisions. A physician order dated 3/19/2026 directed Depakote 500 mg by mouth twice daily for seizure, but during record review the order did not show that informed consent had been obtained before the medication was started. Resident 56 had diagnoses including DM, hyperlipidemia, and CKD, and was documented as having limited decision-making capacity and severe cognitive impairment. A physician order dated 10/15/2025 directed duloxetine 20 mg daily for depression as evidenced by expressing sadness, and the informed consent dated 10/28/2025 listed that indication. A later physician order dated 11/1/2025 changed duloxetine to pain management for diabetic neuropathy, but the informed consent dated 4/28/2026 did not include any indication for use. During interview and record review, RN 1 stated psychotropic medications such as Depakote required informed consent prior to initiation and that it was the licensed staff's responsibility to ensure consent was obtained and maintained in the medical record. The ADON stated another consent should have been obtained when duloxetine's indication changed and that the consent dated 4/28/2026 should have included the indication. The DON stated the resident had a right to be aware of the indication of each psychotropic medication and that the informed consent should have been updated when the indication changed.
Failure to Notify Physician of Repeated Medication and Lab Refusals
Penalty
Summary
The facility failed to ensure the physician was notified in a timely manner of a resident’s repeated refusal of a prescribed medication and an ordered ammonia level laboratory test. Resident 40 was admitted with diagnoses including dementia, psychosis, and heart failure. The resident’s MDS dated 4/7/2026 indicated moderately impaired cognitive skills for daily decision making and dependence on staff for activities of daily living. The H&P dated 7/1/2025 noted fluctuating capacity to understand and make decisions. Resident 40 had physician orders for Midodrine 10 mg by mouth three times daily for hypotension, Divalproex Sodium 125 mg two capsules by mouth two times daily for mood swings and continuous yelling, and an ammonia level laboratory test ordered on 1/22/2026. The consultant pharmacist’s medication regimen review dated 5/1/2026 to 5/11/2026 recommended an ammonia level due to the resident receiving Divalproex Sodium, but the review did not indicate the physician was notified of that recommendation. During record review and staff interviews, the MAR did not show Resident 40’s refusal of Midodrine on 5/26/2026, 5/27/2026, and 5/28/2026, although LVN 3 stated the resident refused the medication three consecutive days. The progress notes also did not document physician notification of those refusals. In addition, the progress notes showed Resident 40 refused the ammonia level on 5/20/2026 through 5/25/2026, and the DON stated the repeated refusals should have been communicated to the physician. The facility policy titled Change in a Resident’s Condition or Status required physician notification for refusal of treatment or medications two or more consecutive times.
Missing Care Plans for Oxygen, Diabetes Medications, and Midodrine
Penalty
Summary
The facility failed to ensure comprehensive care plans were developed for three residents with ongoing treatment needs. Resident 84 was admitted with diagnoses including COPD, pleural effusion, chronic pulmonary edema, and asthma, and the MDS indicated shortness of breath when lying flat and intermittent oxygen therapy on admission and while a resident. During observations, Resident 84 was lying in bed receiving 4 liters of oxygen by nasal cannula, but the medical record did not indicate a care plan for oxygen use. In interview, the LVN and DON stated that Resident 84 should have had a care plan for oxygen therapy. Resident 53 had diagnoses including anemia, dementia, heart failure, and hyperlipidemia, and the record showed physician orders for dapagliflozin-pro-metformin, pioglitazone, and glargine insulin for diabetes. The MDS indicated cognitive skills for daily decision making were intact and the resident required supervision for most ADLs. During record review and interview, the LVN and DON were unable to locate care plan interventions addressing the resident’s diabetic medication regimen, including monitoring requirements, potential adverse reactions, and interventions related to blood glucose management. Resident 40 was admitted with diagnoses including dementia, psychosis, and heart failure, and the MDS indicated moderately impaired cognitive skills for daily decision making and dependence on staff for ADLs. The physician ordered midodrine 10 mg three times daily for hypotension, but the record did not indicate a care plan for its use. The LVN stated there was no care plan developed for Resident 40’s midodrine and that the resident should have had individualized interventions for education, monitoring for side effects, monitoring effectiveness, and other measures related to the medication.
Missing Physician Order for Oxygen Therapy
Penalty
Summary
The facility failed to ensure there was a physician order for oxygen use for one sampled resident who was receiving oxygen. Resident 84 was admitted with diagnoses including COPD, pleural effusion, chronic pulmonary edema, and asthma. The H&P indicated the resident could make needs known but could not make medical decisions. The MDS indicated the resident had shortness of breath when lying flat and was receiving intermittent oxygen therapy on admission and while a resident. During observations, Resident 84 was lying in bed and receiving 4 liters of oxygen through a nasal cannula. During a concurrent interview and record review, the resident’s physician orders showed no order for oxygen therapy. LVN 1 stated oxygen was considered a medication and should not be administered without an active physician order, and the DON stated the resident should have an active physician order for oxygen when receiving oxygen therapy. The facility’s Oxygen Administration policy stated to verify that there is a physician’s order for the procedure and to review the physician’s orders or facility protocol for oxygen administration.
Failure to Maintain Resident Fingernail Hygiene
Penalty
Summary
The facility failed to ensure that two staff-dependent residents had their fingernails trimmed and maintained in a clean manner. Resident 46 was admitted and re-admitted to the facility with diagnoses including bilateral osteoarthritis of the knee, dementia, and dysphagia. The MDS dated 3/20/2026 indicated the resident had moderately impaired cognitive skills for daily decision making and required maximal assistance from staff for ADLs. During an observation on 6/2/2026, Resident 46’s fingernails were long, untrimmed, and had black debris underneath the nail bed. During a later observation and interview on 6/3/2026, Resident 46’s fingernails were again observed to be long and untrimmed. A CNA stated the nails were sharp, long, and required trimming, and explained that nail care was part of CNA responsibilities, including trimming and cleaning nails when they became long and dirty. The CNA stated residents’ nails should be checked daily and noted that residents sometimes scratched their skin, which could break the skin and create an open wound. The IPN and ADON both stated nail care should be part of daily care, and that residents who needed help with cleaning or trimming nails should receive assistance from CNAs or licensed nurses. Resident 12 was admitted with diagnoses including dementia, polyarthritis, and tinea unguium. The H&P indicated the resident had the capacity to understand and make medical decisions, and the MDS indicated the resident was dependent on staff for self-care, including grooming and bathing. During an observation on 6/1/2026, Resident 12 was lying in bed with a thick, yellow, overgrown fingernail on the right first digit that curled beneath the fingertip, and a thick, yellow fingernail on the left fifth digit. A CNA stated the fingernails needed to be trimmed and that CNAs were responsible for providing fingernail care when nails became too long. The IPN stated that if a CNA could not provide fingernail care due to overgrowth, the CNA should notify the charge nurse, who would notify the doctor and wound care doctor for further evaluation. The ADON and DON reviewed the resident’s records and stated the resident should have been provided care for the affected fingernails, and the facility policy required daily cleaning and regular trimming of fingernails to prevent infections.
Broken Bed Headboard and Unsecured Smoking Materials
Penalty
Summary
The facility failed to ensure Resident 18’s room was free of hazards when the resident’s bed headboard was observed broken and hanging away from the bed frame. Resident 18 had diagnoses including dementia, diabetes mellitus, and muscle weakness, and records showed fluctuating capacity to understand and make decisions, impaired cognitive skills for daily decision making, and a need for maximal assistance with activities of daily living. During observation, the headboard was seen broken, with the lower corner touching the floor, and staff confirmed it was not securely attached to the bed frame. During interview, the Housekeeper stated broken headboards should be reported immediately for repair or replacement and that leaving one broken could tip over or have exposed edges that may injure residents. The DOM stated resident beds must be kept in good condition and that a damaged headboard was unsafe and should be reported for immediate repair. CNA 3 and the DON also stated the broken headboard should have been reported and that it created an unsafe environment. The facility also failed to ensure Resident 21’s smoking assessment was updated and smoking paraphernalia was appropriately stored. Resident 21 had diagnoses including type 2 diabetes mellitus, anemia, and hyperlipidemia, with fluctuating capacity to understand and make decisions and moderate cognitive impairment. During observation, a lighter and cigarette were seen on the bedside table while the resident was lying in bed. RN 2 stated smoking materials should be secured in a drawer, but RN 1 later reviewed the smoking assessment and a change-in-condition evaluation showing the resident had been seen smoking in his room and educated about putting others at risk by smoking inside; RN 1 stated the smoking assessment had not been updated after that change and the resident should not have been able to keep his own smoking materials.
Failure to Monitor and Document Foley Catheter Care
Penalty
Summary
The facility failed to assess urine characteristics and document urinary catheter care for one resident with an indwelling urinary catheter. Resident 127 was admitted and later readmitted to the facility, and had diagnoses including neuromuscular dysfunction of the bladder, dependence on a respiratory ventilator, and UTI. The resident’s MDS dated 5/5/2026 indicated moderately impaired cognitive skills for daily decision making, dependence on staff for toileting, bathing, and lower body dressing, and the presence of an indwelling urinary catheter. The resident’s H&P dated 2/10/2026 indicated fluctuating capacity to understand and make decisions. The care plan for the Foley catheter, dated 2/13/2026, directed staff to monitor and document Foley catheter care every shift for urine color, sediments, cloudiness, odor, blood, and amount of output. During review of the TAR for 5/1/2026 through 6/1/2026, the TAR did not show Foley catheter care monitoring performed each shift. The Treatment Nurse stated the lack of consistent monitoring and documentation increased the resident’s risk of infection. The ADON stated Foley catheter care should be monitored and documented each shift by the Treatment Nurse, and that the lack of documentation placed the resident at risk for infection, development of a catheter-associated UTI, and other preventable infection-related complications.
Failure to Provide Required Feeding Assistance
Penalty
Summary
The facility failed to ensure that feeding assistance was provided to a resident who required a feeder during meals. The resident’s record showed diagnoses including dysphagia, lack of coordination, dementia, hypertension, and acute respiratory failure with hypoxia. The MDS dated 5/14/2026 indicated the resident’s cognitive skills for daily decision making were severely impaired and that the resident was dependent on staff for ADLs. A physician diet order dated 5/11/2026 directed a regular, large portions diet with pureed texture, mildly thick consistency, and to provide a feeder. During an observation on 6/1/2026 at 11:00 a.m., the resident was seen in the room scooping a pureed meal with a finger while no staff member was present to provide feeding assistance, cueing, or supervision. During a later observation on 6/3/2026 at 12:36 p.m., the resident was again observed sitting upright in bed with a lunch tray over the lap and scooping food with fingers, with no staff present to assist. CNA 1 stated the resident was a feeder and required staff assistance during meals, and the DON reviewed the record and stated the resident was identified as requiring feeding assistance and should not have been left to eat independently. The facility policy titled Assistance with Meals stated residents shall receive assistance with meals in a manner that meets individual needs, and residents requiring full assistance will be fed with attention to safety, comfort, and dignity.
Pharmacist Recommendations for Ammonia Testing Not Communicated
Penalty
Summary
The facility failed to ensure the consultant pharmacist’s medication regimen review recommendations were communicated to the physician for two residents receiving valproate medications. For Resident 14, the record showed diagnoses including schizophrenia, bipolar disorder, epilepsy, and major depressive disorder. The resident was receiving Depakote 500 mg by mouth twice daily for seizure management, and the consultant pharmacist’s medication regimen review recommended an ammonia level laboratory test. The review did not show that the physician was notified of the recommendation, and the Director of Nursing stated there was no documentation that the physician reviewed the review or addressed the recommendation. For Resident 40, the record showed diagnoses including dementia, psychosis, and heart failure. The resident was receiving Divalproex Sodium 125 mg, two capsules by mouth twice daily for mood swings and continuous yelling. The consultant pharmacist’s medication regimen review also recommended an ammonia level due to the resident receiving Divalproex Sodium. The review did not show that the physician was notified, and the DON stated there was no documentation that the physician reviewed the review or addressed the recommendation. During interview, the DON stated ammonia levels were necessary for both residents and that elevated ammonia levels could cause symptoms such as confusion, sleepiness, behavior changes, decreased alertness, or other serious complications if not monitored and addressed. The DON stated the facility failed to ensure the consultant pharmacist’s drug regimen review recommendations were communicated to the physicians. The facility policy and procedure for Medication Regimen Review stated the consultant pharmacist would provide the DON with a written, signed, and dated report listing irregularities and recommendations.
Medication Administered Outside Ordered Parameters
Penalty
Summary
The facility failed to ensure that insulin and Midodrine were administered within ordered parameters for two residents. Resident 8 had diagnoses including anemia, dementia, diabetes mellitus, glaucoma, and chronic kidney disease. The physician ordered Insulin NPH 14 units subcutaneously each morning and to hold the dose if blood sugar was less than 110 mg/dL. Review of the blood glucose monitoring record showed that 14 units were administered when the resident’s blood glucose was 106 mg/dL, 83 mg/dL, and 84 mg/dL, which was below the ordered threshold. During interview and record review, the DON confirmed that the insulin should have been withheld when the blood glucose level was below 110 mg/dL and stated the doses were given instead of being held as ordered. LVN 6 also stated the insulin should not have been administered for those blood sugar readings. The resident’s MDS indicated severely impaired cognitive skills for daily decision making and dependence on staff for ADLs. Resident 40 had diagnoses including dementia, psychosis, and heart failure. The physician ordered Midodrine 10 mg by mouth three times daily for hypotension and to hold the medication if systolic blood pressure was greater than 130 mm Hg. Review of the MAR showed Midodrine was administered when systolic blood pressure readings were 136 mm Hg, 133 mm Hg, 133 mm Hg, and 136 mm Hg. RN 1 stated the medication should not have been given when systolic blood pressure was above 130 mm Hg, and the licensed nurses were responsible for checking blood pressure and holding the medication when the ordered parameter was exceeded.
Fortified Diet Not Served as Ordered
Penalty
Summary
The facility failed to ensure that one of four sampled residents, Resident 101, who was prescribed a fortified diet, was served a fortified lunch. Resident 101 was admitted with diagnoses including HTN, dysphagia, and dementia. The H&P noted fluctuating capacity to understand and make decisions, and the MDS indicated severe cognitive impairment, dependence on staff for toileting and bathing, and partial assistance needed with eating. Physician orders dated 3/29/2026 directed a fortified diet with minced and moist texture and moderately thick consistency. During a dining room observation, Resident 101’s lunch ticket indicated a fortified high protein diet, but the tray was observed without the fortified mushroom soup that the Dietary Supervisor stated residents on fortified diets would receive. RN 1 stated kitchen staff should have ensured the resident received the fortified lunch diet as indicated on the meal ticket. DA 1 stated she should have communicated the resident’s fortified diet order during tray line so the correct tray could be prepared, and the Dietary Supervisor stated the DA was expected to communicate each resident’s diet order to the cook to ensure the correct meal tray was prepared. The facility policy titled Fortified High Calorie Diet stated the diet is used when additional protein and/or calories are needed.
Failure to Follow Enhanced Barrier Precautions During Resident Care
Penalty
Summary
The facility failed to follow Enhanced Barrier Precautions for Resident 107 when CNA 4 repositioned the resident without wearing the required PPE. Resident 107 was admitted with diagnoses including dementia, hyperlipidemia, dysphagia, UTI, and metabolic encephalopathy. The MDS dated 4/10/2026 indicated the resident’s cognitive skills for daily decision making were severely impaired and that the resident was dependent on staff for ADLs. A physician order dated 5/16/2026 directed Enhanced Barrier Precautions because of a urinary catheter and unhealed wounds. During an observation on 6/1/2026 at 10:05 a.m., CNA 4 was seen repositioning Resident 107 in the resident’s room without PPE. In interview, CNA 4 stated she forgot to don a gown before providing care and acknowledged that gloves and a gown were required before resident contact for a resident on EBP. The DON later reviewed the order and stated that repositioning was a high-contact care activity requiring gloves and a gown before initiating care, and that staff were expected to follow posted precaution signage and use the required PPE consistently during every resident care encounter.
Inaccessible Call Light for Resident with Bilateral Mittens
Penalty
Summary
The facility failed to provide Resident 95 with an appropriate call light system that accommodated the resident’s physical limitations. Resident 95 was admitted and later readmitted to the facility with diagnoses including hemiplegia and dementia. The H&P stated the resident did not have the capacity to understand and make decisions, and the MDS indicated the resident’s cognitive skills for daily decision making were severely impaired and that the resident was dependent on staff for ADLs. The care plan for ADL care deficit stated the resident would use the call light to call for assistance. During observation, Resident 95 was lying in bed with mittens applied to both hands, and the call light was placed across the resident’s chest. The resident was unable to independently grasp or activate the call light because of the mittens. During a concurrent observation and interview, RT 1 stated the resident would not be able to grasp or activate the call light while wearing bilateral mittens and should have had an alternative call system such as a call pad, touch pad, or other adaptive device that could be activated despite the mittens. The facility policy stated residents would have access to the call light and be able to use it to request assistance when needed.
Failure to Document Fall Precautions Each Shift
Penalty
Summary
The facility failed to ensure care plan interventions were documented every shift for one resident identified as a fall risk. The resident had diagnoses including cerebral infarction, hemiplegia, hemiparesis, aphasia, gastrostomy status, and dysphagia. The MDS dated 3/13/2026 indicated the resident’s cognitive skills for daily decision making were severely impaired, and the resident was dependent on staff for bed mobility and ADLs. A fall risk assessment dated 1/14/2026 identified the resident as at risk for falls, and the care plan initiated 11/26/2025 included interventions to keep the bed in low position, use wedges for proper positioning, and ensure correct placement and positioning of bilateral floor mats at the bedside. On 5/5/2026, the resident was found lying on the floor mat on the right side of the bed in a right-side lying position, with bleeding to the right eye and a laceration below the eyebrow. A CT result from the same date showed a right medial orbital wall fracture. During review of nursing progress notes from 4/11/2026 through 5/5/2026, the notes did not indicate that the resident’s floor mats and wedges were checked for placement or that the bed was kept in a low position. RN 2 stated documentation should have been completed by nursing staff on a shift-to-shift basis to verify that fall precautions were in place, and that the implementation of the care plan interventions could not be verified due to the lack of documentation.
Unauthorized Resident Recording and Disclosure Violating Privacy and Confidentiality
Penalty
Summary
The deficiency involves a failure to protect residents’ privacy and confidentiality when a CNA used a personal cell phone to record and photograph two residents without their knowledge or consent, and then shared that content with another CNA. One resident had paraplegia, depression, muscle weakness, dorsalgia, and polyneuropathy, was cognitively intact, and dependent on staff for ADLs. The other resident had diagnoses including seizures, dysphagia, acute kidney dysfunction, and muscle weakness, was able to make needs known but could not make medical decisions, had severely impaired decision-making, and was also dependent on staff for ADLs. Both residents were therefore in a position of dependence on staff for care at the time of the incident. According to CNA 2, on a specific date she recorded a video of the two residents because one resident started an altercation with the other. She stated she recorded the incident for “evidence” and to show CNA 1, acknowledging that recording residents was not part of facility policy and that she should not have recorded or taken photographs of them. CNA 1 confirmed that she received the video on her personal cell phone from CNA 2 and stated that the recording was made for “safety purposes” due to a situation that was perceived as potentially escalating to physical aggression. CNA 1 reported that she did not share or post the video on social media or distribute it to others, but that a family member took her phone without permission and accessed its contents. CNA 1 further stated that this family member sent the video and pictures of the two residents to the facility, and that she notified the facility that her phone had been taken but did not disclose that it contained videos or photographs of the residents because she was unaware that the family member had accessed or distributed them. The DSD reported receiving a text message from an unknown number containing approximately two videos and an undetermined number of photographs of the two residents, along with the names of CNA 1 and CNA 2. The DSD, LVN 2, and the Administrator each stated that staff were required to follow HIPAA regulations, that staff were not permitted to record or possess videos or photographs of residents on personal devices, and that any photographs of residents required consent and had to be for medical purposes as part of the medical record. Facility policies on confidentiality, residents’ rights, and dignity stated that unauthorized release, access, or disclosure of resident information, including video or audio, was prohibited and that staff must protect resident privacy and treat residents with dignity and respect. The videos received by the DSD did not show an altercation between the residents, and staff interviews confirmed that filming residents was not part of the facility’s “Stop and Watch” process, which instead required observation, intervention, and reporting of changes in condition or behaviors to nursing staff.
Plan Of Correction
This Plan of Correction is the facility's credible allegation of compliance. Preparation and/or execution of this plan of correction does not constitute admission or agreement by the provider of the truth or facts alleged, or conclusions set forth in the statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by the provisions of federal and state law. F0583 Personal Privacy/Confidentiality of Records How corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: Corrective actions were immediately implemented for Resident 1 and Resident 2 upon identification of the deficient practice. The facility initiated an investigation on 03/23/2026 and conducted immediate interviews with staff and residents utilizing structured interview tools to assess scope, impact, and additional potential concerns. Interviews confirmed the incident was isolated and no additional residents reported privacy violations or concerns. The staff members involved were removed from duty immediately. Following completion of the investigation, both employees were terminated in accordance with facility policy due to violation of resident rights, HIPAA, and facility confidentiality policies. Both employees completed formal Declarations and Attestations of Deletion of Unauthorized Recordings, confirming removal of all recordings and non-distribution of content. Documentation includes: Ashley Zelaya, CNA – Declaration executed 03/30/2026 at 9:21 AM, attesting deletion of all recordings and acknowledgment of policy violation Leslie Bram Reyes, CNA – Declaration executed 03/26/2026 at 10:42 AM, attesting deletion of all recordings and acknowledgment of policy violation Residents and/or responsible parties were notified. Social Services completed assessments with no identified psychosocial harm. All corrective actions were completed by 03/26/2026. How the facility identifies other residents having the potential to be affected by the same deficient practice and what corrective action will be taken. A facility-wide audit was initiated on 03/25/2026 using the Briarcrest Comprehensive Privacy, Recording, and Resident Rights Audit Tool. The audit included direct observation, staff interviews, and resident interviews to evaluate compliance with privacy practices, personal device use, and HIPAA requirements. Interviews were conducted using standardized staff and resident interview tools to ensure consistency and thoroughness in data collection. Findings from the audit confirmed that no additional residents were affected by the deficient practice and no additional incidents of unauthorized recording or disclosure were identified. Staff were immediately re-educated by Director and staff development on HIPAA Privacy Rule requirements, the facility's prohibition on personal device recordings, and the appropriate use of the Stop and Watch process for reporting changes in resident conditions. This corrective action was completed by 03/27/2026. What measures will be put into place or what systemic changes will the facility make to ensure that the deficient practice does not recur. The facility implemented systemic changes to prevent recurrence of the deficient practice by reinforcing a zero-tolerance policy for unauthorized recordings and strengthening staff accountability related to resident privacy and confidentiality. Staff completed mandatory re-training by the Director of Staff Development on Resident Rights, HIPAA, and Privacy/Confidentiality requirements. Staff were required to re-acknowledge facility policies related to confidentiality and personal device use. The facility implemented routine supervisory rounding to monitor compliance with personal device restrictions. In addition, the facility installed visible signage at the receptionist area clearly articulates that video recording is strictly prohibited inside resident rooms and in any facility areas where residents are present. The facility also posted signage throughout the entire facility, in both English and Spanish, indicating that video recording is not allowed to ensure clear communication to staff, visitors, and all individuals entering the facility. Privacy and HIPAA compliance were further integrated into new employee orientation, annual competencies, and ongoing in-service education. The Director of Staff Development completed initial re-education by 03/27/2026, and staff completed required training by 04/05/2026. How the facility plans to monitor its performance to make sure that solutions are sustained. To ensure sustained compliance, the facility incorporated privacy and confidentiality monitoring into its Quality Assurance and Performance Improvement (QAPI) program. The facility implemented an ongoing monitoring system beginning on 03/25/2026 utilizing the established audit tool, which confirmed that no additional residents were affected, and no further incidents occurred during the initial audit period. The facility will continue monitoring through weekly audits for four consecutive weeks, followed by monthly audits for three months. These audits will include direct observation of staff practices, verification of compliance with personal device policies, and evaluation of adherence to HIPAA and privacy requirements. Audit findings will be documented using standardized tools and reviewed by the Director of Nursing, with results reported to the Quality Assurance and Performance Improvement (QAPI) Committee for analysis and trending. If any issues are identified, immediate corrective action will be implemented, including re-education and progressive discipline as appropriate. If no trends or repeat deficiencies are identified after the monitoring period, the facility will discontinue routine auditing and remove the issue from active QAPI monitoring. Dates when corrective action will be completed. 4/17/2026
Failure to Notify Physician and Document Assessment After Abuse Allegation
Penalty
Summary
The deficiency involves the facility’s failure to follow its policies and procedures for change in condition and abuse/neglect clinical protocol for one resident. The resident, who had dementia, major depressive disorder, anxiety disorder, and a history of right femur fracture, was assessed as having severe cognitive impairment and being dependent for ADLs including toileting, bathing, and bed mobility. On 3/14/2026, the resident reported an allegation of abuse, stating that during a shower a CNA hit her on the head. A Change of Condition (COC) form dated 3/14/2026 showed that the primary care physician (PCP) was notified of the allegation that day at 4:24 p.m., but the COC did not document that a full head-to-toe assessment was completed, did not record any discoloration or bruising, and did not indicate that the PCP was notified of any such findings. In interviews, RN 1 stated that he did perform a full body assessment after the allegation and found a finger-length bluish discoloration on the resident’s left hip on 3/14/2026. However, this skin assessment was not entered into the resident’s medical record and was instead documented on a separate paper form kept in the abuse investigation file. RN 1 also stated he was unable to reach the resident’s PCP regarding both the allegation of abuse and the skin discoloration and did not notify the Medical Director. The DON confirmed that a head-to-toe skin assessment should be completed and documented for all abuse allegations, that any skin discolorations should be reported to the PCP, and that staff should contact the Medical Director if the PCP cannot be reached. Facility policies titled “Change in a Resident’s Condition or Status” and “Abuse and Neglect – Clinical Protocol” required the nurse to assess the resident, document injury assessment findings, and report those findings to the physician after an accident, incident, or allegation of abuse, which was not fully done in this case.
Plan Of Correction
Preparation and/or execution of this plan of correction does not constitute admission or agreement by the provider of the truth or facts alleged, or conclusions set forth in the statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by the provisions of federal and state law. F0580 Notify of Changes (Injury/Decline/Room, etc.) How corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: Resident 2 was immediately reassessed on 03/26/2026 by the Director of Nursing (DON) and licensed nurse. A comprehensive head-to-toe assessment was completed and documented in the medical record. The attending physician (PCP) were notified on 03/26/2026 of the allegation, identified bruise, and current condition. Physician orders were reviewed and implemented as indicated. The resident representative was notified on 03/26/2026. The interdisciplinary team (IDT) reviewed the incident to ensure psychosocial needs were addressed, including monitoring for behavioral changes related to the allegation. The facility corrected the documentation deficiency by ensuring the skin assessment findings were entered into the electronic medical record (EMR) and cross-referenced to the abuse investigation. Staff involved (RN-1) received immediate re-education by the Director of Nursing (DON) on 03/26/2026 regarding timely physician notification, documentation standards, and escalation protocol when the PCP is unavailable. No adverse outcome to the resident was identified. How the facility identifies other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: On 03/28/2026, the Director of Nursing (DON) and/or designee conducted a 12-day look-back audit covering the period of 03/14/2026 through 03/26/2026 for residents who experienced a change of condition, incident, injury, or allegation of abuse. The audit included a review of Change of Condition (COC) documentation, incident/accident reports, and nursing progress notes to verify timely physician notification, completion of head-to-toe-toe assessments, and accurate documentation in the electronic medical record (EMR). No other residents were identified and affected by the deficiency. Licensed staff involved received targeted re-education on notification requirements and escalation protocols by the Director of Staff Developer (DSD). What measures will be put into place or what systemic changes will the facility make to ensure that the deficient practice does not recur: Briarcrest Nursing Center reinforced notification of changes to ensure compliance with physician notification and documentation requirements. A standardized escalation protocol was enforced requiring nursing staff to notify the Medical Director or physician on-call if the attending physician is not reached within one hour, with all attempts documented in the EMR and requiring completion of A head-to-toe assessment, injury documentation, and physician notification details prior to finalizing the entry. The facility reinforced its Abuse and Neglect Clinical Protocol to require that all assessment findings be documented in the EMR. Licensed nursing staff were provided mandatory re-education by Director of Staff and Development (DSD) on 03/27/2026 regarding facility policies, and escalation requirements. The DON and/or designee conducts a 24-hour review of all incidents and COC reports at the clinical start-up and stand down to ensure compliance and immediate correction of any deficiencies. How the facility plans to monitor its performance to make sure that solutions are sustained: To ensure sustained compliance, the facility incorporated privacy and confidentiality monitoring into its Quality Assurance and Performance Improvement (QAPI) program. The Medical records supervisor initiated weekly audits for four weeks beginning 03/26/2026, reviewing a change of condition or incident to ensure timely physician notification, proper escalation, and complete documentation. This is followed by monthly audits for three months. Audit findings are reported to the QAPI Committee monthly with corrective actions implemented as needed. If no negative trends are identified after three consecutive months, the monitoring will be discontinued and removed from active QAPI tracking. If trends are identified, the facility will revise and continue the monitoring plan. Dates when corrective action will be completed: 4/17/2026
Failure to Provide Required Written Bed-Hold Notice at Time of Hospital Transfer
Penalty
Summary
The facility failed to provide a required written Bed-Hold notice to a resident’s responsible party (RP) at the time of the resident’s transfer to a general acute care hospital (GACH). The resident, who had diagnoses including respiratory failure with hypoxia, was originally admitted and later readmitted to the facility, and an H&P dated 2/21/2026 documented that the resident did not have the capacity to understand and make decisions. An MDS dated 3/10/2026 showed the resident was dependent for ADLs such as toileting hygiene, showering/bathing, and bed mobility. The resident was transferred to the GACH for a G-tube replacement, and the discharge summary documented this transfer. Review of the resident’s Bed-hold Informed Consent/Notification Form dated 2/21/2026 showed no indication that a Notice of Bed-hold was provided to the RP after the transfer on 3/10/2026. During interviews, the Business Office Manager stated that the nursing department was responsible for providing the Bed-Hold Notice to residents or their RPs. In a concurrent interview and record review, the DON stated that residents’ beds should be held for seven days when they are transferred to the GACH and that staff would verbally inform RPs about the bed-hold at the time of transfer. The DON also stated she was not aware that written notices should be provided to RPs and acknowledged that, according to the facility’s undated P&P titled “Bed-Holds and Returns,” a written second notice should have been provided to the RP at the time of transfer and that the facility did not follow this P&P. The P&P specified that all residents or representatives are to be provided written information about bed-hold policies at least twice: once in advance of any transfer (e.g., in the admission packet) and a second time at the time of transfer or within 24 hours if the transfer is an emergency.
Plan Of Correction
This Plan of Correction is the facility's credible allegation of compliance. Preparation and/or execution of this plan of correction does not constitute admission or agreement by the provider of the truth or facts alleged, or conclusions set forth in the statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by the provisions of federal and state law. F0628 Discharge Process How corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: Resident 3 was immediately reviewed on 03/27/2026 following identification of the deficient practice. The facility verified that the resident was readmitted on 03/25/2026 without loss of bed or services. On 03/25/2026, the party responsible was contacted by the Director of Nursing (DON) and provided re-education regarding the facility's bed-hold policy, including the 7-day bed-hold provision. A written Bed-Hold Notice was issued retroactively and explained to the party responsible, with documentation placed in the medical record. The interdisciplinary team reviewed the discharge and transfer documentation to ensure all required elements were completed. No adverse outcome occurred. How the facility identifies other residents having the potential to be affected by the same deficient practice and what corrective action will be taken. A 12-day look-back audit was conducted by Medical Records Supervisor from 03/14/2026 through 03/26/2026 for residents transferred to the hospital or on therapeutic leave. The audit focused on compliance with written Bed-Hold Notice requirements at the time of transfer. A total of applicable transfer records was reviewed by the DON and Medical Records Supervisor. No additional residents were identified as missing, written Bed-Hold Notices at the time of transfer. All licensed nurses, unit managers, and admissions staff were re-educated on 03/27/2026 by the Development of Staff Development (DSD) on requirements for discharge documentation and bed-hold notification. What measures will be put into place or what systemic changes will the facility make to ensure that the deficient practice does not recur. The facility will reinforce the systemic corrective actions on discharge process to ensure compliance with the requirements for discharge and bed-hold notification. A standardized Bed-Hold Notice process was incorporated into the transfer workflow, requiring completion of a written notice at the time of transfer or within 24 hours for emergency transfers. The Electronic Medical Record (EMR) was re-enforced to include a required field for Bed-Hold Notice documentation. Licensed nurses, admissions staff, and business office personnel were re-educated on 03/27/2026, by DSD to ensure understanding of regulatory requirements and facility expectations. How the facility plans to monitor its performance to make sure that solutions are sustained. To ensure sustained compliance, the facility incorporated privacy and confidentiality monitoring into its Quality Assurance and Performance Improvement (QAPI) program. The facility will monitor compliance through a structured audit process integrated into the Quality Assurance and Performance Improvement (QAPI) program. Weekly audits of randomly selected residents who experienced hospital transfers will be conducted for four consecutive weeks by Medical Records Supervisor from 03/28/2026 through 04/25/2026, followed by monthly audits for three months from May through July 2026. Audits will evaluate the presence, timeliness, and completeness of written Bed-Hold Notices, including documentation in the EMR and notification of the responsible party. Audit results will be reviewed by the Director of Nursing and/or designee and reported to the QAPI Committee monthly. Any identified non-compliance will result in immediate corrective action, including documentation correction, staff re-education, and progressive discipline if indicated. After three months, the QAPI Committee will evaluate audit findings for trends; if no trends are identified, the monitoring process will be discontinued, and if trends persist, corrective actions and monitoring will be extended to ensure sustained compliance. Dates when corrective action will be completed. 4/17/2026
Incomplete and Inaccurate Documentation After Abuse Allegation
Penalty
Summary
The deficiency involves the facility’s failure to maintain complete and accurate clinical records for one resident following an allegation of abuse. The resident, who had diagnoses including a right femur fracture, dementia, major depressive disorder, and anxiety disorder, and who was assessed as having severe cognitive impairment and dependence for ADLs, reported on 3/14/2026 that a CNA hit her on the head during a shower. RN 1 stated he performed a full body assessment at that time and identified a finger-length bluish discoloration/bruise on the resident’s left hip. However, this full body assessment and the bruise were not documented in the resident’s medical record or on the Change of Condition (COC) form; instead, the skin assessment was recorded on a separate paper form kept in the abuse investigation file. The COC form dated 3/14/2026 documented that the resident’s PCP was notified at 4:24 p.m. and included a PCP recommendation to monitor for pain and episodes of sadness/depression for 72 hours, but the form did not indicate that a full body assessment was completed or that any discoloration/bruise was present. In a later interview, RN 1 stated he had been unable to reach the PCP on that date and acknowledged that the PCP recommendation documented on the COC was incorrect and should not have been entered. The DON confirmed that if staff did not reach the PCP, the recommendation section should have been left blank and attempts to contact the PCP documented in progress notes, and also confirmed that the COC lacked documentation of the bruise found during the assessment. The facility’s policy on charting and documentation required that medical record documentation be objective, complete, and accurate, and that procedures and treatments include assessment data and unusual findings, as well as notification of the physician when indicated.
Plan Of Correction
This Plan of Correction is the facility's credible allegation of compliance. Preparation and/or execution of this plan of correction does not constitute admission or agreement by the provider of the truth or facts alleged, or conclusions set forth in the statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by the provisions of federal and state law. F0842 Resident Records - Identifiable Information How corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice:Resident 2's medical record was immediately corrected on 03/27/2026 to reflect a complete and accurate clinical picture. A late entry was entered by the Licensed Nurse documenting the full body assessment completed on 03/14/2026, including the identified bruise/discoloration to the left hip. The Change in Condition (COC) documentation was corrected to remove the inaccurate "PCP recommendation," and a clarification note was entered indicating that the physician was not reached at the time of the incident. The attending physician was notified on 03/26/2026, and appropriate clinical follow-up was completed. Staff involved (RN 1) received immediate re-education by the Director of Nursing on 3/26/2026 regarding accurate, complete, and non-speculative documentation per facility policy "Charting and Documentation". No adverse outcome to the resident was identified. How the facility identifies other residents having the potential to be affected by the same deficient practice and what corrective action will be taken.A 12-day look-back audit was conducted by Medical Records Supervisor from 03/14/2026 through 03/26/2026 for residents with documented Change in Condition (COC), skin assessments, or incident reports. The audit focused on completeness of documentation, and validation of physician communication. No additional residents were found to have inaccurate physician recommendations documented without verification. Licensed nurses were re-educated on requirements by the Director of Staff Developer (DSD) on 3/27/2026 emphasizing that all clinical findings must be documented in the medical record. What measures will be put into place or what systemic changes will the facility make to ensure that the deficient practice does not recur.The facility reinforced the standardized EMR documentation review for Change in Condition (COC) events requiring completion of a full body assessment, inclusion of all skin findings, and verification of physician communication prior to documenting any recommendations.The abuse investigation workflow was reenforced to ensure that clinical findings are integrated into the medical record to support continuity of care and regulatory compliance. Licensed nurses were re-educated by the DSD ON 03/27/2026 on documentation standards, including accuracy, completeness, and prohibition of speculative entries, as well as confidentiality requirements. These system changes were implemented to ensure medical records remain complete, accurate, and readily accessible, and to prevent recurrence of the deficient practice. How the facility plans to monitor its performance to make sure that solutions are sustained.To ensure sustained compliance, the facility incorporated privacy and confidentiality monitoring into its Quality Assurance and Performance Improvement (QAPI) program.The facility will reinforce the structured monitoring system to ensure sustained compliance. A weekly audit by the Medical Records Supervisor of randomly selected residents with Change in Condition documentation will be conducted for four consecutive weeks focusing on completeness, accuracy, and verified physician communication. Following this period, audits will be conducted monthly for three months. Audit results will be reviewed by the Director of Nursing and reported to the Quality Assurance and Performance Improvement (QAPI) Committee. Any identified discrepancies will result in immediate corrective action, including re-education and documentation correction. If no trends or repeat deficiencies are identified after three months, the issue will be considered resolved and removed from active QAPI monitoring. If trends are identified, the audit frequency will be increased and additional interventions implemented. The facility will evaluate the effectiveness of corrective actions through ongoing compliance rates. Dates when corrective action will be completed. 4/17/2026
Failure to Monitor Behaviors for Resident on Antipsychotic Medication
Penalty
Summary
The deficiency involves the facility’s failure to monitor and document behavioral symptoms for a resident receiving an antipsychotic medication. The resident had diagnoses including bipolar disorder, COPD, and hypertension, with an MDS showing moderately impaired cognitive skills and a need for moderate assistance with several ADLs. The resident was prescribed quetiapine 100 mg at bedtime for bipolar disorder manifested by aggressive angry outbursts, and the care plan directed staff to monitor and record occurrences of these target behavior symptoms. The initial psychiatric evaluation indicated that medications were to be titrated according to the resident’s symptoms. Record review and staff interviews showed that although the resident had been treated with quetiapine since mid-November, behavior monitoring every shift for aggressive angry outbursts did not begin until January 20. RN 1 confirmed that from the start of quetiapine therapy through January 19, the resident was not monitored every shift for aggressive angry outbursts, despite orders and care plan requirements to do so. RN 1 and the DON both stated that licensed nurses were responsible for monitoring and documenting the number of behavior occurrences each shift so that the physician could evaluate the effectiveness of the antipsychotic, identify trends, and consider dose adjustments or GDR. Facility policies on antipsychotic medication use and behavioral assessment required staff to observe, document, and report information on target behaviors and medication efficacy, which was not done for this resident during the identified period.
Failure to Separate Roommates After Verbal Altercation Leading to Resident Injury
Penalty
Summary
The deficiency involves the facility’s failure to follow its own policy and procedure titled “Resident-to-Resident Altercations,” which required staff to separate residents involved in an altercation. Two residents, identified as Residents 4 and 5, were roommates and became involved in a verbal altercation on the evening of 1/9/2026 related to personal belongings, specifically cigarettes and a cell phone that Resident 4 had entrusted to Resident 5 while he was at a general acute care hospital. Licensed vocational nurses (LVN 2 and LVN 3) intervened to de-escalate the situation by returning the phone and providing a cigarette, and both residents appeared calm and were left in the same room to sleep. RN 4 was informed of the verbal altercation by LVN 2 and LVN 3 and, upon checking the room and finding both residents sleeping, did not wake them and instead verbally relayed that one of the residents should be moved once they awoke. No room change or separation was implemented at that time. Resident 4 had a history that included bipolar disorder, COPD, and hypertension, with a Minimum Data Set (MDS) indicating moderately impaired cognitive skills for daily decision-making and use of antipsychotic medication. His History and Physical documented that he had capacity to understand and make decisions. Resident 5’s diagnoses included osteomyelitis of the right ankle and foot, type 2 diabetes mellitus, and acute kidney failure, with an MDS indicating intact cognition and a need for moderate assistance with certain activities of daily living. Despite the facility’s policy requiring separation of residents after an altercation, both residents remained in the same room overnight following the initial verbal conflict. On the morning of 1/10/2026, a second altercation occurred between the same two residents, again related to the cigarettes that Resident 4 had entrusted to Resident 5. Resident 4 reported that upon readmission from the hospital he discovered that Resident 5 had smoked all of his cigarettes, leading to anger, yelling, and derogatory name-calling. CNA 1 heard yelling from the room, entered, and witnessed Resident 5 stand up and push Resident 4 against the nightstand. CNA 1 called for assistance and separated the residents, then informed RN 3. RN 3 observed that the physical altercation had ended and noted an abrasion above Resident 4’s right eyebrow. Documentation in the Change in Condition note and Skin Assessment on 1/10/2026 confirmed that Resident 4 sustained an abrasion measuring 1.5 cm by 1 cm above his right eyebrow as a result of being pushed into the nightstand. During interviews, RN 2, the Social Services Director, the Director of Nursing, and the Administrator all acknowledged that the residents were not separated after the initial verbal altercation and that a room change should have been considered or conducted, consistent with the facility’s policy, to prevent further altercations.
Failure to Complete Required PASRR Resident Review After 30-Day Exempted Stay
Penalty
Summary
The deficiency involves the facility’s failure to complete a required PASRR Resident Review Level 1 screening for a resident with a serious mental illness whose stay exceeded the 30‑day exempted hospital discharge period. The resident was initially admitted and later readmitted, with diagnoses including bipolar disorder, COPD, and hypertension. An MDS dated 1/6/2026 documented moderately impaired cognitive skills for daily decision-making and a need for moderate assistance with toileting, lower body dressing, and personal hygiene, as well as the use of antipsychotic medication. The resident’s H&P indicated the resident had capacity to understand and make decisions. Record review showed physician orders dated 11/18/2025 for quetiapine fumarate 100 mg by mouth at bedtime for bipolar disorder with aggressive angry outbursts, and a care plan dated 11/19/2025 addressing bipolar disorder with administration of antipsychotic medications as ordered. An initial psychiatric evaluation dated 11/21/2025 included a treatment plan to titrate medications according to symptoms, observe for deterioration in function, and provide emotional support for treatment compliance. A PASRR Level 1 screening dated 11/18/2025 indicated the resident tested positive for a serious mental illness. During interviews and concurrent record reviews, the MDS nurse confirmed that every resident has a PASRR Level 1 completed prior to admission and that a positive Level 1 typically triggers a more in‑depth Level 2 mental health evaluation. The PASRR Level 2 letter for this resident, dated 11/18/2025, documented that a Level 2 evaluation was not required due to an exempted hospital discharge, and specified that if the resident remained in the facility longer than 30 days, the facility must resubmit a new Level 1 screening as a Resident Review on the 31st day. The MDS nurse and DON both stated that the resident’s stay had exceeded 30 days and acknowledged that the facility was responsible for submitting a new Resident Review Level 1, which was not done. The facility’s admission policy and the DHCS PASRR Level 2 Screening Process webpage both indicated that for exempted hospital discharges, if the stay exceeds 30 days, the NF must submit a Resident Review Level 1 within the specified timeframe, which did not occur for this resident.
Failure to Care Plan for Resident Use of Bed Grab Bars
Penalty
Summary
The facility failed to develop a person-centered care plan with measurable objectives and interventions addressing one resident’s use of bed grab bars/side rails. The resident had diagnoses including generalized muscle weakness, dementia, and chronic atrial fibrillation, and was documented as having severely impaired cognition on the MDS, as well as lacking capacity to understand and make decisions per the H&P. The resident was dependent on staff for toileting, bathing, and lower body dressing and had a responsible party identified. On observation, the resident was seen in bed with bilateral grab bars in place, which RN staff stated were used to aid in bed mobility and repositioning. Record review on the same date showed there were no physician orders for grab bars and no care plan addressing the use of grab bars or side rails from 10/26/2022 through the date of review. RN 1 acknowledged that, because the resident used grab bars for mobility and repositioning, a care plan should have been developed to reflect this use and to communicate to licensed nurses and CNAs the need to visually monitor the resident’s use of the grab bars, the condition of the equipment, and safety concerns such as entrapment. The DON similarly stated that a care plan should have been developed to indicate the reason for the grab bars and the interventions needed to minimize safety risks, including monitoring the resident’s position in bed and the working condition of the grab bars. The facility’s care plan policy required a comprehensive, person-centered care plan with measurable objectives and timetables to meet each resident’s needs, which was not implemented for this resident’s use of side rails.
Failure to Assess, Obtain Orders, and Secure Informed Consent Before Installing Bed Grab Bars
Penalty
Summary
The deficiency involves the facility’s failure to follow its own process and policy for bed safety and bed rail use before installing bilateral grab bars on the beds of two residents. For the first resident, who had diagnoses including generalized muscle weakness, dementia, and chronic atrial fibrillation, the admission record showed a responsible party, and the MDS dated 11/2/2025 indicated severely impaired cognition with dependence on staff for toileting, bathing, and lower body dressing. The H&P dated 6/9/2025 documented that this resident did not have the capacity to understand and make decisions. Despite this, during observations on 1/20/2026, the resident was seen lying in bed with bilateral grab bars in place, which RN 1 stated were used to aid in bed mobility and repositioning. During concurrent record review for the first resident, the Side Rail Utilization Assessment dated 11/2/2025 indicated that the resident did not have side rails currently in use or requested, even though grab bars were present on the bed. RN 1 stated she did not know when the grab bars were installed and acknowledged that an accurate side rail utilization assessment should have been completed to ensure the resident was safe and able to use the grab bars. Review of the active physician orders on 1/20/2026 showed no order for bilateral grab bars. RN 1 stated that an order was necessary to inform the physician of the need for grab bars and to allow the physician to determine whether installing them was safe, and that grab bars had the potential to be used as a restraint. Review of the electronic health record on 1/20/2026 showed no documentation that informed consent had been obtained from the responsible party for the use of grab bars, and RN 1 confirmed there was no documentation of informed consent. For the second resident, the admission record showed initial admission and readmission dates, with diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting the left side, lack of coordination, and weakness. The MDS indicated moderately impaired cognition and dependence on staff for toileting, bathing, and lower body dressing. The H&P dated 6/25/2025 documented that this resident did not have the capacity to understand and make decisions and identified a surrogate decision-maker. On 1/20/2026, the resident was observed lying in bed with bilateral grab bars, which RN 1 stated were used to aid in repositioning. However, the Side Rail Utilization Assessment dated 1/14/2026 indicated that the resident did not have side rails currently in use or requested, and RN 1 did not know when the grab bars were installed. Review of active orders on 1/20/2026 showed no order for bilateral grab bars, and RN 1 confirmed there was no order for their use. The electronic health record on 1/20/2026 contained no indication that informed consent for grab bar use had been obtained or verified from the resident or surrogate decision-maker, which RN 1 acknowledged. In an interview, the DON stated that, prior to installing side rails on the beds of these residents, the facility was supposed to obtain a physician’s order, conduct a side rail utilization assessment, and verify that informed consent had been obtained. The DON explained that the physician’s order was necessary to ensure the physician agreed that installing side rails was appropriate and safe, that the side rail utilization assessment was needed to show other interventions attempted before using side rails, and that verifying informed consent ensured residents and their representatives were aware of safety risks associated with side rails. Review of the facility’s undated policy and procedure titled “Bed Safety and Bed Rails” showed that consideration was to be given to resident safety, medical conditions, comfort, freedom of movement, and input from the resident and family, and that bed frames, mattresses, and bed rails were to be checked for compatibility and size. The policy also specified that residents at higher risk for injury, including bed entrapment, required additional safety measures and that a resident assessment to determine risk of entrapment should include factors such as medical diagnoses, size and weight, sleep habits, medications, acute interventions, underlying conditions, delirium, toileting ability, cognition, communication, mobility, and fall risk. The policy further required that, before using bed rails for any reason, staff inform the resident or representative about benefits and potential hazards and obtain informed consent, including information on assessed medical needs, risks and mitigation, alternatives attempted and their failure, and alternatives considered but not attempted and the reasons.
Failure to Honor Resident’s Request to Withhold Medical Information From Family Contact
Penalty
Summary
The facility failed to maintain the privacy and confidentiality of a resident’s medical information by notifying a family member about the resident’s change in condition after the resident had clearly withdrawn consent for such disclosures. The resident, who had intact cognition and was documented as self-responsible with capacity to understand and make decisions, had diagnoses including type 2 diabetes mellitus, hypertension, and chronic kidney disease. His admission record listed a family member as his first emergency contact. On 12/24/2025, the resident told an RN that he no longer wanted this family member to be informed about his care because she lived far away, could not visit, and he did not want her to worry. This request was documented in a progress note. The resident later reported feeling frustrated and distrustful of the facility because his request for privacy was not honored. Despite the documented request and the resident’s capacity for decision-making, a Change in Condition Evaluation dated 1/4/2026 showed that the same family member was notified when the resident developed new nasal drip, congestion, and cough. During interviews, the RN acknowledged that the family member should not have been notified and that the resident’s right to privacy and autonomy should have been honored. The DON confirmed that the resident had capacity, was self-responsible, did not want the family member informed of his care, and that the facility did not obtain or act upon the resident’s wishes, including not removing the family member from the face sheet as emergency contact. Facility policies on Resident Rights and Confidentiality of Information and Personal Privacy stated that residents have a right to privacy and confidentiality and that the facility would strive to protect residents’ privacy regarding medical treatment and personal care, but these were not followed in this case.
Improper Linen Use on Low Air Loss Mattress for High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to follow established guidelines for linen use on a low air loss mattress (LALM) for a resident at high risk for pressure injuries and with an existing Stage 4 pressure injury. The resident had severe cognitive impairment, lacked decision-making capacity, and was dependent on staff for all ADLs, including hygiene and positioning. Clinical documentation showed the resident was at high risk for pressure injuries per the Braden Scale and had a Stage 4 pressure injury on the left trochanter. Provider orders directed the use of a P.R.O. Plus LALM for wound management, and the facility’s educational materials and staff statements indicated that only a thin sheet and a disposable pad should be used under residents on a LALM to avoid interfering with pressure redistribution. During observations in the resident’s room, surveyors noted that multiple layers of linens and pads were placed between the resident and the LALM, including a thin white sheet, a folded white sheet, a green pad, and a disposable pad at one time, and later a thin sheet, a folded sheet, and a disposable pad. A CNA acknowledged that only a thin sheet and disposable pad were supposed to be used and admitted placing an extra green pad earlier to assist with repositioning during wound treatment and leaving a folded sheet under the disposable pad to make it easier to pull the resident up in bed, despite knowing this was not correct. The treatment nurse and DON confirmed that additional linen layers under a resident on a LALM reduced the mattress’s effectiveness in offloading pressure and that staff had been educated to minimize linen layers. The facility’s user manual for the P.R.O. Plus support surface allowed for specific items such as a draw or slide sheet and an incontinence barrier pad, but the observed practice exceeded these guidelines, leading to the cited deficiency.
Failure to Follow Two-Person Assist and Side Rail Orders Resulting in Bed Fall
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident’s environment was free from accident hazards and that adequate supervision and assistive devices were provided as ordered. The resident had a history of hemiplegia and hemiparesis following a stroke affecting the left side, hypertension, and aphasia, and was documented as severely cognitively impaired. The resident’s MDS dated 12/25/2025 indicated dependence on staff for oral hygiene, toileting, bathing, dressing, personal hygiene, and rolling left and right. The History and Physical dated 10/14/2025 stated the resident did not have the capacity to understand and make decisions, and a Fall Risk Assessment dated 12/25/2025 identified the resident as at risk for falls. The resident’s care plan for Activities of Daily Living Self-Care Deficit, initiated 10/13/2025, indicated the resident required two staff participation to reposition and turn in bed. A document titled Roll Left and Right Task, dated 12/26/2025 at 8:10 p.m., defined the resident as dependent for rolling, meaning the helper did all the effort or that two or more helpers were required. The DON and RN 1 both stated the resident required a two-person assist in bed mobility and repositioning because the resident was unable to hold herself up or keep herself from rolling over the edge of the bed when on her side. The facility’s Repositioning policy required staff to check the care plan, assignment sheet, or communication system to determine the resident’s specific positioning needs, including the number of staff required. Despite these documented needs and orders, on 12/26/2025 at approximately 9 p.m., CNA 4 provided incontinence care and repositioned the resident onto her right side alone, without a second staff member and without side rails in place. During the brief change, the resident began to shift and slide, causing the upper portion of her body to roll toward the floor, and CNA 4 assisted the resident to the floor in a controlled manner. CNA 4 stated she had previously repositioned and changed the resident’s diaper alone without issues, did not check the Kardex for the required level of assistance, and acknowledged the resident had no side rails on the bed. Review of the resident’s orders dated 10/14/2025 showed an order to apply bilateral half side rails to enhance bed mobility and repositioning, which were not in place at the time of the incident. The DON stated that precautions were not in place to safely reposition the resident and that the fall could have been prevented if a second person had been present and the ordered side rails had been installed.
Failure to Timely Report Alleged Staff-to-Resident Abuse
Penalty
Summary
The facility failed to report an allegation of staff-to-resident physical abuse to the California Department of Public Health (CDPH) within the required timeframe. A resident with severe cognitive impairment, quadriplegia, and total dependence on staff for activities of daily living was re-admitted to the facility and later alleged to his responsible party that he had been hit by an unidentified male CNA. This allegation was communicated to the facility's Interdisciplinary Team during a meeting, and both the Director of Nursing (DON) and the Administrator acknowledged awareness of the allegation. Despite facility policy and federal requirements mandating that all allegations of abuse be reported within two hours, the DON and Administrator confirmed that the incident was not reported to the State Agency. The facility's own policies, reviewed during the investigation, also specified the need for timely reporting of abuse allegations. The failure to report the incident as required constituted a deficiency in the facility's abuse reporting procedures.
Failure to Investigate Alleged Staff-to-Resident Abuse
Penalty
Summary
The facility failed to investigate an allegation of staff-to-resident physical abuse involving a resident with severe cognitive impairment, quadriplegia, and multiple complex medical needs, including a tracheostomy and gastrostomy. The resident, who was dependent on staff for all activities of daily living and mobility, was reported by his responsible party to have alleged being hit by an unidentified male CNA. This allegation was communicated during an Interdisciplinary Team meeting, and both the Director of Nursing and the Administrator acknowledged awareness of the report. Despite the facility's policies requiring thorough and timely investigation of all abuse allegations, no investigation was initiated into the reported incident. Both the DON and the Administrator confirmed that the allegation met the criteria for physical abuse and should have been investigated, regardless of the resident's or responsible party's ability to provide specific details about the perpetrator or timing. The lack of investigation was contrary to the facility's own policies and federal requirements.
Failure to Perform Timely Neurological Assessments After Alleged Head Injury
Penalty
Summary
Registered Nurse (RN) 1 did not perform neurological assessments (neuro-checks) at the required frequency and intervals for a resident who was allegedly struck on the head by a male Certified Nursing Assistant (CNA). The resident, who had severe cognitive impairment, quadriplegia, a tracheostomy, and a gastrostomy, was dependent on staff for all activities of daily living and mobility. Following the alleged incident, neuro-checks were ordered to be performed every 30 minutes, then hourly, as documented in the resident's record. However, the neuro-checks were not conducted at the scheduled times, with some checks being significantly delayed and others performed in rapid succession, not adhering to the required intervals. The Director of Nursing (DON) confirmed that the neuro-checks were not performed according to the ordered schedule and emphasized the importance of timely assessments to identify any changes or complications. The facility's policy and procedure for neurological assessments required staff to perform neuro-checks at the frequency ordered, but this was not followed in this case. The failure to adhere to the neuro-check schedule was documented in the resident's records and acknowledged by the DON during the investigation.
Failure to Safeguard Resident Information and Maintain Medical Records
Penalty
Summary
The facility failed to safeguard resident-identifiable information and/or did not maintain medical records for each resident in accordance with accepted professional standards. This deficiency was identified through surveyor observation or review, indicating that the required protocols for protecting confidential resident information or proper record-keeping were not followed as expected. No additional details about specific residents, staff actions, or the circumstances leading to the deficiency are provided in the report.
Failure to Develop Individualized Dementia Care Plan
Penalty
Summary
The facility failed to develop an individualized care plan for a resident diagnosed with dementia, epilepsy, and generalized anxiety disorder. The resident was admitted with fluctuating mental capacity and required maximal assistance with activities of daily living, including dressing, toileting, personal hygiene, transfers, and bed mobility. Documentation reviewed included the resident's admission record, history and physical, Minimum Data Set, and psychiatric notes, all of which indicated significant cognitive and functional impairments, such as impaired judgment, concentration, and attention span, as well as a blunt or constricted affect. Interviews with nursing staff confirmed that no care plan addressing the resident's dementia had been created. Both an LVN and an RN acknowledged the importance of having an individualized care plan to guide staff in providing appropriate interventions and care for the resident. The facility's own policy required comprehensive, person-centered care plans with measurable objectives and timetables, but this was not implemented for the resident in question.
Failure to Develop and Implement Resident-Centered Care Plan for Fluid Restriction
Penalty
Summary
The facility failed to develop a comprehensive, resident-centered care plan for a resident who had physician orders for fluid restriction. The resident was admitted with a history of edema, chronic heart failure, and chronic kidney disease, and was able to make medical decisions. Physician orders were documented for fluid restriction, initially set at 1.5 liters per day and later reduced to 1 liter per day, with specific instructions for dietary intake and the use of a condom catheter for intake and output monitoring. Despite these orders and the resident's changing clinical condition—including peripheral edema, abnormal lung sounds, weight gain, vesicles on the lower legs, and later respiratory distress—the facility did not create or update a care plan to address the fluid restriction or the use of the condom catheter. Multiple record reviews and staff interviews confirmed that no care plan was developed or revised to reflect the resident's needs or the physician's orders, even as the resident's condition worsened. The facility's own policy required person-centered care plans with measurable objectives and timetables to meet each resident's needs, and for care plans to be updated as conditions changed. However, the care plans for this resident were found to be non-existent or not specific and resident-centered, failing to address the physician-ordered interventions and the resident's evolving symptoms.
Failure to Prevent Allergen Exposure Due to Inadequate Tray Card Identification and Verification
Penalty
Summary
The facility failed to follow established procedures for accommodating a resident's documented food allergies, resulting in the resident being served fish despite a known seafood allergy. The resident, who had diagnoses including dysphagia and a gastrostomy, was on a regular, no added salt, pureed diet with specific restrictions against white bread, milk, citrus, cheese, caffeine, and seafood. The resident's tray card, which should have clearly indicated these allergies, displayed the seafood allergy in small letters and not in pen, making it less noticeable to dietary staff. As a result, the kitchen assistant did not see the allergy and served the resident pureed fish. The resident consumed the fish, believing it to be chicken, and subsequently experienced an allergic reaction, including itching and numbness, requiring administration of Benadryl. Interviews with staff revealed lapses in the tray verification process. The dietary supervisor acknowledged the error and noted the allergy was not prominently marked on the tray card. The kitchen assistant confirmed the allergy was not easily visible, and the licensed vocational nurse admitted to not checking the tray due to other duties. The director of nursing emphasized the importance of double-checking trays to prevent such incidents. Facility policies required tray cards to list allergies and for staff to check trays for accuracy, but these procedures were not adequately followed, leading to the resident receiving an allergen-containing meal.
Failure to Implement Enhanced Barrier Precautions During Wound Care
Penalty
Summary
The facility failed to implement its infection prevention and control measures for two of four sampled residents by not ensuring that staff wore appropriate personal protective equipment (PPE) and that required signage was posted. Specifically, a Licensed Vocational Nurse (LVN) and a Restorative Nursing Assistant (RNA) entered the room of a resident on Enhanced Barrier Precautions (EBP) without donning isolation gowns and proceeded to perform a wound dressing change. The resident had a stage 4 pressure ulcer, quadriplegia, and moderate cognitive impairment, and was dependent on staff for activities of daily living. Physician orders indicated the resident was to be on EBP due to open wounds, and the facility's policy required gown and glove use during high-contact care activities such as wound care. A similar failure was observed with another resident, where no EBP signage or isolation cart was present at the room entrance, and the same staff did not wear isolation gowns while performing a wound dressing change. This resident had osteomyelitis, hemiplegia, hemiparesis, diabetes mellitus, and severe cognitive impairment, and was also dependent on staff for daily care. Physician orders required daily wound care for a diabetic ulcer. Both staff members acknowledged during interviews that they forgot to use gowns and were aware of the need to wear PPE for residents on EBP. The Director of Nursing confirmed that EBP precautions, including gown use, should be followed for residents with wounds.
Failure to Supervise Medication Administration and Assess for Self-Administration
Penalty
Summary
A deficiency occurred when a Licensed Vocational Nurse (LVN) failed to supervise the medication administration for a resident who had not been assessed by the Interdisciplinary Care Team (IDT) for self-administration of medications. The resident, who had diagnoses including osteoarthritis, hypertensive urgency, and diabetes mellitus, was observed holding a cup with multiple medications at her bedside without a licensed nurse present. The LVN stated that the medications were left with the resident because she preferred to take them on her own, despite the absence of an IDT assessment or a physician's order permitting self-administration. Review of the resident's records showed that she required supervision or assistance for activities of daily living, such as eating and oral hygiene, and had no cognitive impairment. The medication orders included several drugs for blood pressure, diabetes, and other conditions, with specific administration times. The medications were scheduled for administration at a set time, but the LVN left them unattended at the resident's bedside, and the resident was not supervised during the process. Interviews with facility staff, including a CNA, RN, and the Director of Nursing (DON), confirmed that medications should not be left unattended and that an IDT assessment is required before a resident can self-administer medications. The facility's policy also requires an IDT evaluation to determine if self-administration is safe and appropriate. In this case, the required assessment and care planning had not been completed prior to the incident, and the medications were left with the resident without proper authorization or supervision.
Failure to Notify Physician of Sustained Abnormal Vital Signs
Penalty
Summary
The facility failed to assess and notify a resident's medical doctor when the resident exhibited sustained tachycardia and tachypnea. The resident, who had a history of chronic respiratory failure, tracheostomy dependence, pneumonia, and sepsis, was admitted with severely impaired decision-making capacity. On the day of the incident, the resident's respiratory rate was consistently above 30 breaths per minute and heart rate above 100 beats per minute for several hours, as documented in the flowsheets. Despite these abnormal vital signs, there was no immediate assessment or notification to the medical doctor. Nursing staff, including an LVN and an RN, were aware of the elevated vital signs but did not notify the physician until several hours after the onset. The RN acknowledged being too busy to address the situation promptly, and the LVN did not call the physician earlier. The facility's policies required immediate assessment and physician notification in the event of abnormal vital signs, but these protocols were not followed. As a result of the delayed response, the resident's condition was not managed in a timely manner, and the resident was eventually transferred to a general acute care hospital for evaluation. Interviews with nursing staff and the Director of Nursing confirmed that the abnormal vital signs should have prompted earlier physician notification and intervention, in accordance with facility policy.
Failure to Prevent Accidents and Implement Fall Prevention Measures
Penalty
Summary
The facility failed to ensure a safe environment free from accident hazards and did not provide adequate supervision to prevent accidents for two residents. For one resident with a history of bilateral femur fractures, morbid obesity, contractures, functional quadriplegia, and cognitive impairment, the care plan and assessments indicated total dependence on staff for bed mobility and toileting hygiene, requiring two-person assistance. Despite this, a CNA performed perineal care and repositioning alone, without a second staff member. During this process, the resident was turned to the side and subsequently fell from the bed, resulting in bilateral femur fractures, hypovolemic shock, and the need for surgical intervention and blood transfusions. Multiple staff interviews and record reviews confirmed that the resident's care plan and assessments consistently documented the need for two-person assistance, and that the use of an air mattress increased instability, further necessitating additional support during care. Another resident, with diagnoses including generalized muscle weakness, reduced mobility, osteoporosis, and moderately impaired cognition, was identified as high risk for falls and had a care plan specifying that the call light should be within reach and fall mats should be present on both sides of the bed. Observations over several days revealed that the call light was not within the resident's reach and that fall mats were not present at the bedside, despite the resident's history of falls and care plan interventions. Staff interviews confirmed that fall mats had not been in place for at least a month, and that the absence of these interventions increased the risk of injury from falls. The facility's own policies required the environment to be free from accident hazards, for care plans to be comprehensive and person-centered, and for fall prevention interventions to be implemented based on individual risk factors. In both cases, the facility failed to follow its policies and the residents' care plans, resulting in a serious injury for one resident and increased risk for another.
Failure to Evaluate MDS Nurse Competency and Performance
Penalty
Summary
The facility failed to ensure that the Minimum Data Set Nurse (MDSN) demonstrated the required competencies for her position and did not conduct annual evaluations of her ability to accurately perform MDS assessments. Interviews with the Assistant Director of Nursing (ADON) and the MDS Nurse Consultant (MDSC) revealed that while the MDSN had access to the Resident Assessment Instruction (RAI) manual and was expected to follow it, there were no routine or annual performance evaluations in place to assess her competency in conducting MDS assessments. The MDSC stated that although she audited random MDS assessments monthly, this did not involve direct observation of the MDSN performing the assessments. A review of the MDSN's employee record indicated that her responsibilities included conducting resident assessments and ensuring accurate documentation of residents' health and wellness problems. The facility's policy required annual performance evaluations for all employees, but the Administrator confirmed that no such evaluation had been conducted for the MDSN. This lack of competency evaluation and oversight placed all residents at risk of receiving inaccurate MDS assessments, which could negatively impact their care plans.
Failure to Implement Infection Control Measures and Equipment Maintenance
Penalty
Summary
The facility failed to implement proper infection prevention and control measures for five residents, as evidenced by multiple observations and record reviews. For two residents with enhanced barrier precautions (EBP) orders due to the presence of indwelling medical devices (a gastrostomy tube and a urinary catheter), there was no EBP signage or indicators posted outside their rooms, and no personal protective equipment (PPE) was available. The facility's policy required such signage and PPE to alert staff to the need for EBP, but these were not in place, as confirmed by the Infection Preventionist Nurse. For another resident, oxygen tubing, nebulizer, and respiratory setup bag were not changed according to the facility's policy, with equipment observed to be dated several weeks prior. Similarly, a different resident's oxygen humidifier was not changed as ordered by the physician, with the device observed to be in use well past the scheduled change date. These lapses were confirmed by staff interviews and review of facility policies, which required weekly changes of respiratory equipment to prevent infection. Additionally, a resident's suction tubing and suction filter were found lying on the floor, contrary to infection control standards and facility policy. Staff interviews confirmed that respiratory equipment should not be on the floor and should be replaced if contaminated. The facility's own policies and staff statements indicated that these practices were not followed, placing residents at risk for infection due to improper handling and maintenance of respiratory equipment.
Failure to Label and Return Resident's Personal Belongings
Penalty
Summary
A deficiency occurred when the facility failed to label the personal belongings of a resident who was admitted with schizophrenia and dementia, resulting in severe cognitive impairment and a need for partial to moderate staff assistance. The resident's family member brought in a blanket for her comfort, which was documented on the admission inventory list. However, after the blanket was laundered by the facility, it was not returned to the resident. The inventory list at discharge did not indicate that the blanket was returned, and the item was later found in outdoor storage by the Social Services Director (SSD). The SSD confirmed that the blanket was not labeled with the resident's name or any other identifier, which led to confusion among laundry staff regarding its ownership. The facility's policy required all personal belongings to be labeled to ensure they could be returned to the correct resident if misplaced. The lack of labeling resulted in the blanket being stored rather than returned to the resident, contrary to the facility's policy of providing a homelike environment and supporting residents' use of personal belongings.
Failure to Ensure Call Light Accessibility and Assistance with Adaptive Devices
Penalty
Summary
Staff failed to accommodate the needs and preferences of two residents by not ensuring their call lights were within functional reach and by not assisting one resident with her prescribed glasses. For one resident with a history of stroke, hemiplegia, and quadriplegia, the call light was placed on the side of the bed corresponding to his paralyzed hand, making it inaccessible. Despite care plan instructions to anticipate and meet his needs by ensuring the call light was within reach, the resident reported being unable to call for assistance due to the placement of the device. Staff interviews confirmed awareness of the resident's inability to use his right hand and the importance of call light accessibility. Another resident, with major depressive disorder, anxiety, and severely impaired cognition, was observed with a pad call light clipped to her chest, which she was unable to activate due to hand weakness and stiffness. Staff acknowledged that the call light placement was not functional and that the resident often relied on her roommate or yelling for help. After repositioning the call light to her abdomen, the resident was able to use it with her elbow. Staff interviews further confirmed the need for resident-specific assessment of call light placement to ensure accessibility. Additionally, the same resident required bifocal glasses for vision improvement, as prescribed by an eye doctor. Although the glasses were provided, the resident was unable to put them on independently due to limited hand mobility and reported that staff did not assist her when requested. The glasses remained unused in her bedside dresser until a staff member assisted her, at which point she expressed improved vision and a desire to wear them consistently. Staff interviews confirmed a lack of awareness regarding the resident's need for glasses and the importance of assisting residents with adaptive devices when necessary.
Inaccurate MDS Assessments for Multiple Residents
Penalty
Summary
The facility failed to ensure that Minimum Data Set (MDS) assessments for four residents were completed and documented accurately, resulting in the transmission of inaccurate data to CMS regarding their health status. For one resident with major depressive disorder and anxiety, the MDS inaccurately indicated severely impaired cognition and failed to document the need for glasses, despite optometry records and interviews confirming the resident required bifocal glasses for vision. The MDS nurse assessed vision adequacy based on the resident's ability to wave in the hallway, without following the Resident Assessment Instrument (RAI) manual's guidance to assess close vision and use of corrective lenses. Interviews with facility leadership confirmed that the assessment was not conducted according to protocol, and the MDS did not reflect the resident's actual needs. Another resident with lack of coordination, muscle weakness, and failure to thrive was assessed in the MDS as having no upper or lower extremity impairments, despite physician orders for passive range of motion and physical therapy records indicating the resident could not perform active range of motion in any extremity. The Director of Rehabilitation and MDS nurse both acknowledged that the MDS was inaccurate and did not reflect the resident's true functional limitations. Direct observation confirmed the resident was unable to move any extremities or follow commands, further supporting the inaccuracy of the MDS documentation. A third resident with diabetes, congestive heart failure, and muscle weakness was documented in the MDS as having intact cognitive skills and being dependent for ADLs, but the oral/dental status was coded incorrectly, failing to reflect the resident's lack of natural teeth and broken dentures. The MDS nurse confirmed the error and acknowledged the importance of accurate MDS coding for care planning. A fourth resident with multiple fractures, morbid obesity, contractures, and functional quadriplegia was assessed in the MDS as requiring substantial or maximal assistance for bed mobility, but CNA documentation and therapy records indicated total dependence. The MDS nurse did not observe the resident or document interviews with staff, resulting in an inaccurate assessment. Facility policies required comprehensive assessments using direct observation and communication with staff, but these procedures were not followed.
Failure to Complete Required Level II PASRR Evaluation for Resident with Mental Illness
Penalty
Summary
The facility failed to ensure that a required Level II PASRR (Preadmission Screening and Resident Review) evaluation was completed for a resident with multiple mental health diagnoses, including schizophrenia, delusional disorder, bipolar disorder, and depression. The resident's records indicated intact cognitive skills and the need for assistance with daily activities. A Level I PASRR screening identified the need for a Level II evaluation to determine eligibility for specialized mental health services, but there was no evidence that this evaluation was completed or followed up on. Interviews with facility staff revealed a lack of knowledge and responsibility regarding the PASRR process. The Social Services Director stated she was not responsible for PASRR follow-up and was unfamiliar with the process, while the MDS nurse also indicated a lack of understanding and that the facility did not have a process in place for Level II PASRR evaluations. The Director of Nursing confirmed that there was no policy or procedure for PASRRs, and that the absence of follow-up could delay necessary mental health treatment for the resident.
Failure to Develop and Implement Comprehensive Care Plans for Multiple Residents
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for seven residents, resulting in unmet needs and lack of required interventions. For one resident with a history of falls and impaired mobility, the call light was not within reach and fall mats were not placed at the bedside on multiple occasions, despite care plan directives and a recent fall with injury. Staff interviews confirmed the absence of fall mats and the inability of the resident to access the call light, contrary to the documented care plan interventions. Two residents receiving insulin for diabetes did not have care plans addressing their insulin use, including necessary monitoring and interventions. Staff interviews confirmed the absence of these care plans, and it was acknowledged that such plans are necessary to guide staff in monitoring blood sugar, food intake, and potential side effects. Similarly, another resident who required corrective lenses did not have a care plan for their use, and staff were unaware of the need to assist the resident with wearing glasses, which were found unused in the resident's room. Additional deficiencies included the lack of care plans for seizure medications for one resident, a blood thinner for another, and missing teeth for a further resident, despite these conditions being documented in medical records and requiring specific interventions. One resident using a self-releasing wheelchair seat belt for safety also did not have an active care plan addressing its use. Staff interviews and record reviews consistently revealed that these omissions left staff without guidance on necessary interventions, monitoring, and support for these residents' specific needs.
Failure to Maintain Resident Nail Hygiene and Grooming
Penalty
Summary
The facility failed to maintain proper grooming and personal hygiene for two residents who were unable to perform activities of daily living independently. One resident was observed with long fingernails and a brown substance underneath, and reported that no one had cut or cleaned his nails. This resident had diagnoses including dementia and major depressive disorder, with severely impaired cognitive skills and required moderate assistance for ADLs. The care plan for this resident specified that fingernails should be cleaned daily and trimmed as necessary, but this was not done. A CNA confirmed that the resident's fingernails were long and dirty, and acknowledged that CNAs were responsible for daily nail care. Another resident was observed with long toenails and a black substance underneath and around the toenails. This resident also had dementia and major depression, with severely impaired cognitive skills and required moderate assistance for ADLs. The care plan indicated daily cleaning and trimming of nails, which was not provided. The CNA and the Director of Staff Development both confirmed that nail care should be performed daily and that the residents' nails should have been addressed. Facility policies also required daily cleaning and regular trimming of nails for residents unable to perform self-care, but these were not followed for the two residents.
Failure to Set Low Air Loss Mattress According to Resident Weight
Penalty
Summary
A deficiency was identified when a resident at high risk for pressure ulcers was observed lying on a low air loss mattress (LALM) that was not set according to the resident's weight. The mattress was set to a weight higher than the resident's actual weight of 293 lbs, as indicated on the control panel and confirmed by staff. Both a Licensed Vocational Nurse and a Treatment Nurse acknowledged that the mattress setting was incorrect and that the harder surface resulting from the higher setting was not appropriate for the resident's skin integrity needs. The facility's policy and the manufacturer's guidelines both require that the LALM be adjusted based on the resident's weight. The resident involved had multiple diagnoses, including morbid obesity, acute respiratory failure with hypoxia, congestive heart failure, anemia, and cirrhosis of the liver. The resident was bedbound, had severely impaired cognition, and was dependent on staff for all activities of daily living. The Braden Scale assessment indicated a high risk for pressure ulcer development. Staff interviews confirmed that all licensed nurses were responsible for checking the LALM settings every day and every shift, but this was not done, resulting in the resident being exposed to an improperly set support surface.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 7,411 citations issued within 25 miles in the last 12 months — including the 24 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Bell Gardens
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Bell Convalescent Hospital | 0.8 mi | ★★★★★ | 32 | 0 |
| Villa Del Rio | 1.4 mi | ★★★★★ | 12 | 0 |
| Maywood Skilled Nursing & Wellness Centre | 2 mi | ★★★★★ | 27 | 0 |
| California Post-acute Care | 2.2 mi | ★★★★★ | 63 | 0 |
| Lynwood Post Acute Care Center | 2.2 mi | ★★★★★ | 39 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.